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Strategic Planning in Health Professions Education: Scholarship or Management?

Byrne, Niall PhD; Cole, Donald C. MD; Woods, Nicole PhD; Kulasegaram, Kulamakan PhD; Martimianakis, Maria Athina PhD; Richardson, Lisa MD, MA; Whitehead, Cynthia R. MD, PhD

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doi: 10.1097/ACM.0000000000002852
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Abstract

At the outset of a recent strategic planning process at the Wilson Centre, an academic health sciences educational research center in Toronto,1 we undertook our tasks along traditional lines. These lines involved examining previous strategic plans, establishing core research areas of the Centre’s mandate as well as new foci of research, and identifying actions essential to the Centre’s ongoing successful development. For all intents and purposes, we were doing what we understood to be typical of strategic planning in academe. It soon became evident, however, that to dig deeper into our agenda—and to uncover how well informed our planning process was by research and theory—we needed to explore both the management literature and the literature relevant to health professions education and research. As theory-driven research is the sine qua non of the Centre’s existence, we sought a means of self-examination that was aligned with our theoretical research mandate. In evolving a scholarly approach to strategic planning, we reflected upon (1) dominant research discourses in health professions education research, (2) the experience of other research and education centers in general2–4 and health professions education research centers specifically,5,6 and (3) emerging areas of development at the Centre.

After completing this exercise, we considered the larger questions of what assumptions underpin different models of strategic planning and how strategic planning is seen as adding value to academic medicine. In this article, to elaborate on these questions, we examine relevant literature and set out our emergent scholarly model. We start with a brief review of earlier Centre strategic planning reviews, followed by a synopsis of the relevant literature, practice, and theory. We then describe the methodology we used and how we think our scholarly approach differs from what is typical in our own experience and more generally in the field of health professions education research. Finally, we share some lessons learned that may be useful to others in improving on what we did.

Prior Strategic Planning Reviews

The Centre celebrated its 20th anniversary in 2016.1 As of 2019, it comprises 20 scientists, 29 fellows and graduate students, and 4 support staff engaged in health professions education research and research training. In its relatively short history, it has experienced 4 reviews, each focused on strategic planning, completed by external experts or facilitators in health professions education. These reviews were the result of a change in the Centre’s leadership and/or the University of Toronto Faculty of Medicine’s requirement for 5-year reviews. Whether or how these reviews contributed to the growth or productivity of the Centre has, unfortunately, not been documented adequately. Given this, each of the reviews stands as a milestone—or, some might argue, a tombstone—in the history of the Centre. It is as if the strategic planning exercise, once accomplished, served history rather than the future—a condition, we suspect, that may be commonplace. We acknowledge that we are not alone in seeking more forward-looking, self-reflective approaches. The Accreditation Council for Graduate Medical Education, for example, has required annual reviews of residency programs since 2014, aiming for continuous quality improvement rather than relying on less frequent extensive analyses.7 We consider our approach to be aligned with this desirable trend.

Strategic Planning Models: Relevant Literature, Practice, and Theory

A management approach to strategic planning has its own set of theories, from Taylor8 to Drucker9 to Mintzberg,10 but in its adoption by the academe, its theory base is mainly implicit, and its practice relies on precedent and history. Strategic planning reports regarding academic health centers11–15 consist mostly of atheoretical articles with an instructive show-and-tell quality. Using PubMed, we searched the academic literature for applications of theory to strategic planning in academic and research settings, using combinations of search terms such as strategic plan*, academ*, theor*, education, and research. We also searched for strategic plans and planning processes on the websites of other Canadian health professions education centers and departments. From these searches, only one theory-based article emerged.16

There are many publications describing use of management models to inform strategic planning in both the for-profit17–19 and nonprofit20–22 sectors. Model types range from linear23 to organic.24–26 The linear models usually focus on the identification of mission, selection of organizational goals, and identification of specific strategies followed by specific actions—all of which, in essence, represent a management-by-objectives approach. These models tend to result in a regularly updated plan plus a budget realignment to accommodate the actions specified. The organic models, in contrast, typically address organizational cultural values, vision, periodic reviews, and continuous adjustments to address emergent contingencies. Absent from most model descriptions is an evidentiary base for (1) who should lead strategic planning, (2) who should be engaged in strategic planning, (3) what evaluation model and measures are deemed appropriate, and (4) what theory best connects and explains the data. Kohn’s thesis27 is an exception to the typical approaches in that it identifies multiple sources of evidence for informing hospital administration decision making.

In opting for a scholarly approach,28 we are not refuting the efficacy of a management approach. Rather, in our experience, we have observed that a management approach to strategic planning, whether linear or organic, typically is not led by an explicit theory but, rather, is conducted using an implicit theory of pragmatism that reinforces success and rejects failure.29 While pragmatism may be an appropriate choice in some (perhaps even many) strategic planning processes, we suggest that having an array of theoretical options to draw upon may provide our field with intriguing and valuable additional ways to think about and plan for future growth.

We are mindful that strategic planning, review, and accreditation are all variants of governance evaluation practice30 and that many pragmatic approaches may be grounded in the practical orientation of an organization. Because governance evaluation practice is ubiquitous, necessary, and resource-intensive in academic medicine, it seemed appropriate to embed our planning exercise within a theory-based research methodology aligned with the mission and values of the Centre.

The importance of theory cannot be overstated because theory acts to integrate research findings and provides an explanation of the data gathered in an otherwise wide-ranging field. We are not the first to endorse the value of theory for strategic planning. Wolf and Floyd,30 for example, advocated a theory-based approach to strategic planning, offering a menu of social, psychological, and economic theories. We did not consider the Wolf and Floyd model ideal for our process for 2 reasons: First, it was addressed to the private sector rather than to the education or research sectors, and, second, their menu of theories was not helpful for us because it did not place each of them in an appropriate context.

As we proceeded in our planning process, we became aware of the lack of fit between strategic planning as typically described, without theory, in the health professions education literature and our emergent experiences and conceptions of strategic planning. Recognizing the need to incorporate our emergent experiences led us to Ursula Franklin’s31 theory that emphasizes universities as institutions designed for growth rather than production. This theory has, to date, been absent from the research literature of medical education. Franklin was a metallurgist, physicist, and educator who taught at the University of Toronto for many decades. In The Real World of Technology, a book based on her 1989 Massey Lectures, Franklin broadly examines uses of technology in many aspects of society and sets forth her theory of growth versus production models, making frequent references to the critical importance of the distinction between these models in education.31(pp20–24) In growth models, there is an understanding that growth can be encouraged (but not decreed) in a supportive environment. The learner develops at his or her own rate. Production models assume that conditions can be controlled and designed to ensure predictable end products regardless of context.31(pp20–21) Franklin argues that the dominant technological discourses that shape understandings of societal structures and systems are focused on a production model. She considers the production model highly problematic in education, as it leads to prescriptive practices, and suggests that a growth model better enables holistic practices:

Although we all know that a person’s growth in knowledge and discernment proceeds at an individual rate, schools and universities operate according to a production model. […] [A]ll of us who teach know that the magic moment when teaching turns into learning depends on the human setting and the quality and example of the teacher—on factors that relate to a general environment of growth rather than on any design parameters set down externally. If there ever was a growth process, if there ever was a holistic process, a process that cannot be divided into rigid predetermined steps, it is education.31(pp22–23)

Given that the Centre supports high-quality educational practices through theoretically rigorous research, Franklin’s growth theory seemed appropriate as a means of orienting and making sense of our planning process, implementing our findings, and interpreting the results. Our idea, as a collaborative academic unit, was to define and implement a scholarly model consonant with the research ethos of the Centre.

Case Study: Our Methodology

Viewing the strategic planning process as a scholarly rather than a management exercise, we present our methodology here as a modified case study,32,33 informed by theory31 and subject to further testing by comparable academic institutions.33 The Centre opted to (1) ask D.C.C., a University of Toronto professor and general member of the Centre, to facilitate the planning; (2) co-involve N.B., an emeritus professor of the Centre; and (3) include a broad array of Centre scientists and trainees. This process occurred over the 2017 calendar year. Figure 1 shows the relationship between Franklin’s theory,31 the steps in the strategic planning process, and priority action items addressed by 5 area working groups (described below).

Figure 1
Figure 1:
The Wilson Centre’s scholarly strategic planning process in 2017: Steps of the process and action strategies established, informed by Ursula Franklin’s growth model of education.31 Abbreviations: S indicates step in the strategic planning process; A, action strategy identified through the strategic planning process; WC, The Wilson Centre.

To provide context for the new strategic plan, N.B. undertook an analysis of the 4 previous strategic recommendations (2002–2015). This analysis made evident those activities that are continuous and that form the core of the Centre. It also helped identify the areas of current interest and concern representing gaps in the overall agenda of the Centre. From this analysis, together with formal and informal discussions among the Centre’s faculty members, 5 areas for exploration of priorities emerged: (1) individual and collective growth of scientists, and engagement in (2) local collaborations/networks, (3) national collaborations/networks, (4) international collaborations/networks, and (5) Indigenous health professions education research. Beyond these original 5 areas, citizenship and funding were identified as additional strategic priorities. Citizenship was addressed to ensure that the priorities of the Centre were in line with those of the medical school and teaching hospital. The most appropriate example of this alignment was the Centre’s Indigenous scholarship focus, which aligned with the University of Toronto’s and the Faculty of Medicine’s strategic priorities.

The Centre scientists and trainees were invited to choose participation in 1 of the 5 area working groups, which met between January and June 2017. The Centre director (C.R.W.) appointed additional Centre members to each working group, as necessary, to broaden and deepen potential perspectives. The leaders of the working groups, together with D.C.C., N.B., and C.R.W., initially brainstormed approaches to and relevant resources for a discussion of Centre directions. Through an iterative process, each working group produced a report containing general principles guiding the area, specific strategic target(s), and actions necessary to achieve those targets. Using these group reports as data, we synthesized principles and established 7 action strategies (laid out in the Main Features of the Centre’s 2017 Strategic Plan section, below).

Development and Evolution of Our Strategic Planning Model

In common with typical strategic planning protocols, we identified priority areas and actions required to achieve these priorities. Additionally, we defined characteristics of our approach that differed from those of management models. Chart 1 summarizes the similarities and differences between our scholarly model and the conventional management model for strategic planning. Although we did not explicitly define our scholarly model initially, in discussion with the faculty, fellows, and graduate students, we made sure it was understood that we were engaged in a scholarly exercise with a research focus. Similarly, we did not begin with a firm grasp of the appropriateness of Franklin’s theory31 to this work. Rather, as we moved through the process, Franklin’s theory emerged more explicitly in our deliberations. We view this learning, emergent approach as a strength of our process.

First, it was important that the planning be democratic—that is, that all of the Centre’s personnel be given a choice about which of the 5 areas they wished to explore. Second, every working group member was strongly encouraged to be engaged, and engagement enhanced their commitment to the agreed-upon actions. This emphasis on each member’s contribution to the future success of the Centre reinforced the sense of ownership of the planning process. Third, instead of relying solely on past Centre experience, we searched the literature for examples of effective strategic planning related to academic medicine institutions and to management organizations. Fourth, it was deemed essential that the planning and its actions be informed by theory, in this case by Franklin’s emphasis on growth rather than production.31 The implications of adopting Franklin’s theory are that research and education are viewed as dynamic entities, subject to change based on evidence and/or innovation. Thus, the results of our scholarly model of strategic planning are best described as actions, where the term action connotes the achievement of a new plateau of performance and the continuation of the Centre’s plan, rather than outcomes, where the term outcome signals the end of an event or the completion of a goal.31

Fifth, we embraced our research approach to data gathering and analysis. We viewed the entire exercise as a case study. A case study methodology is appropriate in situations where an in-depth knowledge of real-life context is required.32,33 We were aware that in undergraduate and postgraduate medical education there is a mandate to conduct an institutional self-study as a component of fulfilling the accreditation requirements.34 We deepened such a self-study by conducting our case study with a rigorous, evidential, and theoretical underpinning. Moreover, we used a modified case study method with the aim of enhancing theory that could relate to comparable conditions in academic settings. Finally, we designed the planning process to ensure an action-oriented agenda by requiring each of the 5 groups to delineate the actions, both short- and medium-term, needed to meet the priority areas.

Main Features of the Centre’s 2017 Strategic Plan

Seven action strategies were established (Figure 1), the first of which was knowledges creation. The Centre is by mandate and definition both part of an academic health center and itself a university education research center whose core agenda is to produce new knowledge in the field of health professions education through research. In all our deliberations, knowledges creation was viewed as the foundation and driving force of the Centre’s strategic plan, with a diverse meaning of knowledges—hence the pluralization.

The second, scholars’ development, was seen as an essential counterpart of knowledges creation. The Centre has assumed the obligation to train new scientists and researchers through its fellowship program, by conducting workshop-style ateliers (on qualitative research, applications of methodologies to health professions education research, and presentation skills) and other courses related to specific skill sets, by supporting its scientists to supervise trainees in various degree programs, and by preparing for approval of a new PhD program. (At the time of the strategic planning, the proposed PhD program, which was viewed as a potential core component of the Centre, was pending university approval. The PhD program proposal has since been approved, and the first cohort began in September 2018.)

The third, engagements, relates to the activities—local, national, and international—through which the Centre shares its research accomplishments, ideas, and methods: by presenting at scholarly meetings, conducting ateliers, and accepting visiting scholars. Closely related, the fourth, collaborations, involves activities of the Centre’s scientists with colleagues of other organizations; these activities are usually focused on research and programs enhancing research capacity. One example is the Centre’s engagement with the university and medical school in Addis Ababa, Ethiopia.

In the course of our planning process, it became obvious that the Centre’s record keeping needed to be upgraded to enable us to define the Centre’s activities more accurately and completely. Accordingly, the fifth action strategy, analytics, is intended to track and record decisions and their consequences related to each of the 7 action strategies. The sixth, good citizenship, addresses the alignment of the Centre’s priorities with those of the Faculty of Medicine, the University of Toronto, and the University Health Network. An example, as noted above, is Indigenous initiatives. The idea of incorporating Indigenous scholarship in the Centre had been informally discussed from time to time. As a consequence of the strategic plan, the Centre hired the medical faculty’s co-lead of Indigenous medical education as the director of Indigenous scholarship. The final action strategy, funding, outlines the aim to identify the costs associated with new initiatives and to seek external funding, where appropriate.

Our strategic planning report was approved by both the University of Toronto and University Health Network authorities in October 2017. Since receiving approval, we have divided 27 action items into short-term (1-year) and medium-term (2-year) categories. Responsibilities for leading and completing these action items have been taken up by different faculty members. We expect to evaluate the successes of this process and its remaining challenges in 2020. It is evident now that, in addition to defining and executing priorities of the planning, we have initiated a system of data collection that will allow for an analytics approach to measuring the Centre’s progress over time in areas including international and national collaborations, involvement of visiting scholars, bibliometrics, presentations, awards, editorial board contributions, and student supervision by affiliated scientists.

Some Lessons Learned

Our experience has led us to conclude that we have created a scholarly strategic planning model that is applicable to academic units both in the university and teaching hospital environments. Although making a conscious and explicit attempt to move away from a management model was not a dominant feature of our agenda, doing so has been a refreshing experience for all involved.

Our initial concern was to ensure that all of the Centre’s scientists were engaged in the planning. We recognize that this represented a democratic, nonhierarchical approach. Gradually, it emerged that we were on a path that was scholarly in the sense that we grasped the importance of theory as both a means of explaining observations and of sustaining continuity, bridging the past and future. We learned from Franklin31 that focusing on outcomes is a tenuous endeavor because research and education are fluid and continuous by their nature. Thus, the language of management models did not capture the ethos of continuity characteristic of the academe. Finally, the idea of a scholarly approach was the key feature leading to engagement and commitment of scientists to the process. The language of research and scholarship was essential to our scientists’ engagement, and they viewed the process as being in their own interest and not an external management mandate. Moving forward, we hope to engage in broader scholarly discussions with colleagues at other academic institutions and organizations about different models of strategic planning.

Acknowledgments:

The authors acknowledge the involvement of Dr. Shiphra Ginsburg in the strategic planning process, the very helpful comments on the manuscript by Dr. Robert Paul, the assistance of Carrie Cartmill with manuscript preparation, and the editorial contributions of Jennifer Campi.

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Chart 1 Similarities and Differences Between the Wilson Centre Scholarly Model and the Conventional Management Model for Strategic Planninga

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